Provider Demographics
NPI:1881129369
Name:KING, LISA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-869-8865
Mailing Address - Fax:510-569-6271
Practice Address - Street 1:3100 SUMMIT ST FL 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3412
Practice Address - Country:US
Practice Address - Phone:510-869-8865
Practice Address - Fax:510-869-6271
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006001363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95006001OtherSTATE MEDICAL LICENSE